Prostate-specific antigen testing across the spectrum of prostate cancer

Abstract

Prostate-specific antigen (PSA) is a protein produced by the prostate, and this protein may be elevated for several reasons, including prostatitis, benign prostatic hypertrophy and/or cancer. PSA is not cancer-specific, cannot be used as a cancer marker and it has been demonstrated that there is no level of PSA that is definitive for prostate cancer. The value of the PSA test varies when used for screening, diagnosis, prognosis or as a signal of disease recurrence. Misuse of the test for screening has created unnecessary anxiety and costs, and has led to the significant overdiagnosis and overtreatment of men. More important than whether or not to screen is how one acts upon the data from a single test; with the exception of extremely high double- or triple-digit levels of PSA, it is prudent only to use a single PSA determination as a baseline, with biopsy and cancer treatment reserved for those with significant PSA changes over time, or for those with clinical manifestations mandating immediate therapy. Using the PSA test to monitor disease progression or recurrence is appropriate, provided one understands that absolute levels of PSA are rarely meaningful; it is the relative change in PSA levels over time that provides insight, but not definitive proof of a cancerous condition necessitating therapy. PSA secretion is under hormonal control and thus PSA levels may be affected differently by the type of drug therapy, by the stage of a patients’ disease, and by genetic factors suggesting some men are ‘high PSA producers’. Until a validated alternative test for prostate cancer is found and adopted, the current flawed PSA test needs to be used more judiciously and not used for routine screening as studies have demonstrated that screening, as defined, does not lead to a reduction in patient mortality. All men, their families and their physicians need to understand the significant limitations of PSA testing.